Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
Integrated NCLEX/NGN Practice Test — 100 Items
FUNDAMENTALS (10 items)
1. (SBA) [Domain: Safe & Effective Care Environment —
Management of Care; Cognitive: Application]
A nurse is delegating tasks to a nursing assistant (NA).
Which task is most appropriate to delegate to the NA for a
newly admitted client with right-sided weakness from a
stroke?
A. Teach the client how to perform upper-extremity range-
of-motion exercises.
, B. Perform a full bed bath and assist the client to the
bedside commode.
C. Complete the initial nutritional screening and start the
feeding plan.
D. Conduct the initial neurologic assessment and
document findings.
E. Administer the client's first dose of antihypertensive
medication.
Answer: B.
Rationale:
• A: Teaching therapeutic exercises requires assessment and
teaching skill — not appropriate to delegate.
• B (correct): Bathing and assisting to commode are ADLs
within NA scope when client stable.
• C: Nutritional screening and starting feeding plan require
assessment and clinical judgment by licensed nurse.
• D: Initial neuro assessment is a comprehensive assessment
— RN responsibility.
• E: Medication administration is RN task.
2. (SATA) [Domain: Physiological Integrity — Basic Care &
Comfort; Cognitive: Application]
A client with stage II pressure ulcer on the sacrum is
admitted. Which nursing actions should the RN include in
, the plan of care? (Select all that apply.)
A. Reposition client every 2 hours while in bed.
B. Massage reddened bony prominences to increase
circulation.
C. Use a pressure-redistribution mattress.
D. Cleanse wound daily with hydrogen peroxide.
E. Document wound size, depth, and drainage
characteristics daily.
Answers: A, C, E.
Rationale:
• A (correct): Frequent repositioning reduces pressure.
• B: Do not massage reddened bony prominences — may
cause tissue damage.
• C (correct): Pressure-redistribution surfaces are
appropriate.
• D: Hydrogen peroxide can damage granulation tissue; use
normal saline or wound cleanser.
• E (correct): Accurate wound documentation is required for
monitoring.
3. (SBA) [Domain: Psychosocial Integrity — Therapeutic
Communication; Cognitive: Application]
A client with newly diagnosed terminal cancer asks, “How
long do I have?” The most therapeutic response by the
, nurse is:
A. “You won’t live long if you don’t start treatment.”
B. “I don’t know exactly, but let’s talk about what’s most
important to you now.”
C. “You’ll be fine—miracles happen every day.”
D. “Why do you want to know? It will only upset you.”
E. “I can’t answer that — it’s between you and the doctor.”
Answer: B.
Rationale:
• A: Judgmental/fearful statement — inappropriate.
• B (correct): Honest, supportive, redirects to client values
and priorities.
• C: False reassurance — not therapeutic.
• D: Dismissive, blocks communication.
• E: Abdicates nursing role in supporting discussion.
4. (Matrix multiple-response) [Domain: Physiological Integrity
— Safety & Infection Control; Cognitive: Analysis]
Instructions: For each listed intervention (rows), mark Y if
it reduces central line–associated bloodstream infection
(CLABSI) risk, or N if it does not. (Columns: Y / N)
Interventions:
A. Use chlorhexidine for skin antisepsis.
B. Change dressing using sterile technique on a scheduled
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
Integrated NCLEX/NGN Practice Test — 100 Items
FUNDAMENTALS (10 items)
1. (SBA) [Domain: Safe & Effective Care Environment —
Management of Care; Cognitive: Application]
A nurse is delegating tasks to a nursing assistant (NA).
Which task is most appropriate to delegate to the NA for a
newly admitted client with right-sided weakness from a
stroke?
A. Teach the client how to perform upper-extremity range-
of-motion exercises.
, B. Perform a full bed bath and assist the client to the
bedside commode.
C. Complete the initial nutritional screening and start the
feeding plan.
D. Conduct the initial neurologic assessment and
document findings.
E. Administer the client's first dose of antihypertensive
medication.
Answer: B.
Rationale:
• A: Teaching therapeutic exercises requires assessment and
teaching skill — not appropriate to delegate.
• B (correct): Bathing and assisting to commode are ADLs
within NA scope when client stable.
• C: Nutritional screening and starting feeding plan require
assessment and clinical judgment by licensed nurse.
• D: Initial neuro assessment is a comprehensive assessment
— RN responsibility.
• E: Medication administration is RN task.
2. (SATA) [Domain: Physiological Integrity — Basic Care &
Comfort; Cognitive: Application]
A client with stage II pressure ulcer on the sacrum is
admitted. Which nursing actions should the RN include in
, the plan of care? (Select all that apply.)
A. Reposition client every 2 hours while in bed.
B. Massage reddened bony prominences to increase
circulation.
C. Use a pressure-redistribution mattress.
D. Cleanse wound daily with hydrogen peroxide.
E. Document wound size, depth, and drainage
characteristics daily.
Answers: A, C, E.
Rationale:
• A (correct): Frequent repositioning reduces pressure.
• B: Do not massage reddened bony prominences — may
cause tissue damage.
• C (correct): Pressure-redistribution surfaces are
appropriate.
• D: Hydrogen peroxide can damage granulation tissue; use
normal saline or wound cleanser.
• E (correct): Accurate wound documentation is required for
monitoring.
3. (SBA) [Domain: Psychosocial Integrity — Therapeutic
Communication; Cognitive: Application]
A client with newly diagnosed terminal cancer asks, “How
long do I have?” The most therapeutic response by the
, nurse is:
A. “You won’t live long if you don’t start treatment.”
B. “I don’t know exactly, but let’s talk about what’s most
important to you now.”
C. “You’ll be fine—miracles happen every day.”
D. “Why do you want to know? It will only upset you.”
E. “I can’t answer that — it’s between you and the doctor.”
Answer: B.
Rationale:
• A: Judgmental/fearful statement — inappropriate.
• B (correct): Honest, supportive, redirects to client values
and priorities.
• C: False reassurance — not therapeutic.
• D: Dismissive, blocks communication.
• E: Abdicates nursing role in supporting discussion.
4. (Matrix multiple-response) [Domain: Physiological Integrity
— Safety & Infection Control; Cognitive: Analysis]
Instructions: For each listed intervention (rows), mark Y if
it reduces central line–associated bloodstream infection
(CLABSI) risk, or N if it does not. (Columns: Y / N)
Interventions:
A. Use chlorhexidine for skin antisepsis.
B. Change dressing using sterile technique on a scheduled
